The Courtyards at Pasadena

In the surveyor’s words

From the most serious findings on record at The Courtyards at Pasadena, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 27, 2024

  Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (CR #1) of 5 residents reviewed for quality of care. The facility failed to ensure CR #1, who was cognitively impaired and wearing a wander guard, received adequate supervision when the facility sent him to the doctor's office unsupervised. CR #1 left the doctor's office and was found outside of a building in the rain by a bystander. An immediate jeopardy (IJ) was identified on 1/26/24 at 9:40 a.m. […]

• Immediate jeopardy, isolatedF684Sep 3, 2021

  Based on interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 1 of 5 residents (CR# 1) reviewed for quality of care. The facility failed to implement CR#1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure LVN A reported CR#1's critical lab level and medication change during the change of shift to the oncoming nurse for implementation resulting in the resident not receiving ordered medication .CR#1 was found unresponsive 16 hours later. […]

• Actual harm, isolatedF686Oct 21, 2022

  Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 1 resident (resident #210) out of 7 residents reviewed for pressure ulcers. 1. Facility failed to assess or evaluate Resident #210's pressure ulcers on admission. 2. Facility failed to perform wound care for resident #210 from 09/15/2022 to 09/19/2022 while in the facility. These failures placed residents at risk for developing worsening of pressure injuries, severe pain, infections, and [CONDITION(S)]. Findings include: On 10/20/2022 at 1:58 p.m. […]

• No harm, potential for more than minimal, widespreadF812Mar 19, 2025

  Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. -The facility failed to ensure that one of one deep fryer grease was clean. -The facility failed to ensure that the stove in the kitchen was kept clean. -The facility failed to ensure that the rail above the stove was free of grease. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination Kitchen observation and interview with the Dietary Manager on 03/17/25 at 8:45AM, revealed the following: The cooking area revealed the deep fryer had dark looking grease with… […]

• No harm, potential for more than minimal, patternF755May 14, 2026

  Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of six residents (Resident #37 and Resident #20) reviewed for pharmacy services. 1. The facility failed to ensure LVN B followed the manufacturer's instructions to prime the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in the required amount of Insulin to be administered to Resident #37 on 05/12/26. 2. […]